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UM 2. To make utilization decisions, the
managed healthcare organization uses
written criteria based on sound clinical
evidence and specifies procedures for
applying those criteria in an appropriate
manner:
- The criteria for determining medical
necessity are clearly documented
and include procedures for applying
criteria basedon the needs of
individual patients and characteristics
of the local delivery system.
- The managed healthcare organization
involves appropriate, actively
practicing practitioners in its development
or adoption of criteria and
in the development and review of
procedures for applying criteria.
- The managed healthcare organization
reviews the criteria at
specified intervals and updates
them, as necessary.
- The managed healthcare organization
states in writing how
practitioners can obtain the UM
[Utilization Management] criteria
and makes the criteria available
to its practitioners upon request.
- At least annually, the managed
care organization evaluates the
consistency with which the health
care professionals involved in
utilization review apply the
criteria in decision making.
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CC 1: Health care services provided directly or by arrangement are
appropriate:
- In scope to meet the health care needs of the population served;
- To the health care needs, as influenced by socio-cultural
characteristics, of the population served;
- To the network’s mission;
- To the network’s contractual obligations.
CC 8: When the network or an external entity conducts a utilization
review of a licensed independent practitioner’s or a network component’s
care that results in denial of payment, decisions by the
licensed independent practitioner or network component regarding
ongoing care or discharge are based on the care required by the
member’s assessed needs.
CC 8.1: When utilization review results in an adverse utilization management
decision, the network provides the criteria for the decision
and information regarding appeal to the licensed independent practitioner
responsible for the member’s care.
JCAHO provides examples of implementation. "These examples
are simply ideas for your network to consider."
Example of implementation for CC 8: The network requests the
review criteria used by any external entity that carries out a utilization
review on the network’s members. The review criteria are made
available to those within the network responsible for treatment and
discharge decisions. When the external utilization review organization’s
recommendation conflicts with the member’s medical care
requirements, justification for the course of action taken is documented.
Information from the external entity is collected and incorporated
into the network’s assessment and improvement activities.
RI 2: The network provides for member involvement in care and
treatment decisions.
RI 2.1: The network provides an authorization process for care and
treatment that is timely, efficient, and meets member health care
needs.
The network’s process for authorizing care and treatment includes:
- Providing members with a description of the treatment
authorization process.
- Initial decisions made by an appropriately trained health care
professional using evidence-based, network approved criteria to
authorize admission, care, and transition to another care setting.
- A review of all initial treatment authorization denials by a
physician, dentist, or behavioral clinician prior to notifying the
member or their representative(s) of an adverse
determination.
- Informing members in a timely manner, in writing, when a
request to authorize treatment has been denied.
- Informing members of the basis and reason(s) for the adverse
determinations.
- Informing members of the review criteria used to make the
determination.
- Providing members with information as to whether, and under
what circumstances, investigational procedures are available
and are covered by the network.
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